Researchers reveal the impact of moral distress on clinicians during the pandemic and supportive actions

During the COVID-19 pandemic, healthcare organizations, leaders, researchers, and practitioners have attempted on the fly to deal with the inherent stresses, strains, and struggles related to an unprecedented healthcare crisis in modern times. UNC School of Medicine's Jeffrey Sonis, MD, MPH, who is investigating this issue broadly, published two research articles on two specific aspects: the impact of moral distress on healthcare workers and the actions healthcare organizations made – or did not make – that affected the level of support they received from their workforces.

Published in PLOS ONE and the Journal of Healthcare Management, respectively, the studies offer insights from an online survey that Sonis and colleagues conducted in late 2020 among internists who are members of the American College of Physicians, the largest medical specialty organization in the United States.

Moral distress is the discomfort that health workers feel when they are prevented, by individuals, institutions or situations, from doing what they believe is morally right. For the PLOS ONE article, Sonis, Associate Professor in the UNC Department of Social Medicine and the UNC Department of Family Medicine, and colleagues evaluated of the overall intensity of moral distress among U.S. internal medicine physicians (internists) during the pandemic.

"Although overall intensity of moral distress was low, approximately one in eight internists had high levels of moral distress, "Sonis said. "Thirteen percent of U.S. internists had moral distress levels that they rated as distressing, intense or worst possible."

Internists who had low levels of moral distress did not have increased odds of adverse mental health outcomes compared to internists who reported no moral distress. However, those with high levels of moral distress had markedly elevated odds (approximately 5 to 18 times the odds) of screening positive for anxiety, depression, posttraumatic stress disorder, burnout, and intention to leave patient care.

Two factors were associated with higher levels of moral distress among U.S. internists: perceived risk of dying if infected with COVID-19 and the number of patients seen face-to-face with COVID-19 in the previous two weeks. Perceived organizational support – the belief that their employer cared about their well-being – was associated with lower levels of moral distress.

"Among U.S. internists who have high levels of moral distress, the risk of adverse mental health is high," Sonis said. "They are also more likely to intend to leave patient care. This may affect the ability of the U.S. to maintain an adequate physician workforce during the pandemic."

"However", Sonis added, "healthcare organizations have the ability to reduce moral distress among physicians by taking specific actions to support their healthcare workers during the pandemic."

Supporting the team

For the Journal of Healthcare Management paper, Sonis and UNC Family Medicine's Don Pathman, MD, MPH, and colleagues set out to identify specific COVID-19-related policies and actions that health organizations can do to promote (or diminish) perceived organizational support and the effect of that support on mental health of front-line clinicians during the COVID-19 pandemic. Perceived organizational support is the degree to which employees feel that their organization cares about them and values their contributions.

Using the same national survey of internists who are members of the American College of Physicians, the researchers evaluated ten health organization policies and actions. They reported that three were strongly associated with higher levels of perceived organizational support, after controlling for potential confounding factors.

The three factors are:

• guaranteeing adequate personal protective equipment for frontline healthcare workers,
• making sure leaders listen to healthcare workers' concerns about COVID-19, and
• offering opportunities for healthcare workers to discuss ethical concerns related to caring for patients with COVID-19.

"The COVID-19 pandemic has unleashed a flood of moral dilemmas for frontline clinicians," Sonis said. "It is not surprising that offering opportunities to discuss ethical concerns was strongly related to internists' perceptions that their health organization supported them."

One health organization action – warning or sanctioning healthcare workers who refused pandemic deployment or spoke up about healthcare worker safety – was associated with lower perceived organizational support. "Although healthcare organizations have been concerned about maintaining a workforce adequate for the pandemic," Pathman said, "punitive personnel policies are likely to backfire."

High levels of perceived organizational support among the internists in the study were associated with lower levels (by about 1/2 to 2/3) in rates of screening positive for anxiety, depression, posttraumatic stress, burnout and intention to leave patient care.

Sonis noted, "We think that by implementing tangible support policies positively associated with perceived organizational support and avoiding punitive ones, healthcare organizations may be able to reduce adverse mental health outcomes and moral distress among their physicians during the COVID-19 pandemic."